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Rose Hoffman used to eat no more than an apple before a four-hour practice.

The 14-year-old Bexley gymnast said she gave it little thought and felt that she had plenty of
energy as she flipped and tumbled her way toward the next competition.

Late last year, though, Rose learned that she’d been taking in too few calories for a growing
athlete who spends 20 hours or more in the gym each week.

The news came the hard way: A stress fracture in her back tipped off doctors to the possibility
of a cluster of problems — improper nutrition, absent or infrequent menstrual periods and decreased
bone-mineral density — known as “female athlete triad syndrome.”

In the worst cases, patients lose significant bone mass that can’t be rebuilt, predisposing them
to fractures later in life.

The syndrome is especially common in athletes in sports in which lithe bodies equal a
competitive advantage; those who are judged, such as figure skaters; and those who require small
uniforms, such as volleyball players, said Dr. Anastasia Fischer, a sports-medicine expert at
Nationwide Children’s Hospital. But doctors also see it in girls and women who don’t compete.

Sports-medicine experts are increasingly identifying the problem in part because of a broader
new definition of the syndrome and in part because of growing attention to spotting it before it
does irreversible damage. At Children’s, the sports-medicine team has routinely been screening
patients for the syndrome for four months, Fischer said.

The nutritional piece of the triad puzzle isn’t always linked to what most people would think of
as an eating disorder. Often, athletes restrict their diets by minimizing carbohydrates or
eliminating dairy, but they aren’t suffering from a psychological problem, experts say

“We have a lot of really picky eaters. We have girls who have a really narrow range of what they
will eat and what they don’t,” Fischer said. In other cases, they burn more calories than they take
in.

“I had no idea that I wasn’t eating enough,” said Rose, who hopes to return to gymnastics soon.
She felt fit and strong and had never been a scale-watcher. And she didn’t feel any pressure from
coaches or teammates to keep her weight down, she said.

Finding problems early is important because bone density can take years to rebuild, and the bulk
of bone growth takes place before the person is 20 years old, said Dr. Troy Smurawa, a
sports-medicine specialist at Akron Children’s Hospital.

Advocates are working to educate high-school coaches and nurses as well as medical
professionals, said Jeanne Nichols, a San Diego exercise and nutrition expert who researches the
condition and is president of the Female Athlete Triad Coalition board. Her group’s efforts have
the support of the NCAA, she said.

In a 2006 study of 170 high-school female athletes, Nichols’ team found that 18 percent had
disordered eating, 24 percent had menstrual irregularity and 22 percent had low bone mass.

Nichols said her group wants to dispel the myth that not having a menstrual period is OK. Among
distance runners, in particular, it can even become a goal, she said.

Instead, a lack of a period should be a gateway to a discussion about overall health, she
said.

Shelly Hoffman, Rose’s mother, said her daughter was fortunate to learn of the problem before it
caused significant loss of bone density.

“I didn’t think as a parent I understood how many calories she was burning,” Mrs. Hoffman said. “
You need a whole lot more fuel than you think you do when you’re training at that level.”

A dietitian has since helped Rose learn how to better maintain a healthy body, both in terms of
calories and the quality of the food she’s eating.

Rose said she learned that she needs about 2,000 calories a day when she’s not training and
several hundred more when she is.

“I had no idea this was a thing. I think it’s important that everyone is aware of this,” she
said.